Lessons from Abroad

Lessons from Abroad

In Brief:AIMS President Brian Lee Crowley was a featured speaker at an international conference in Washington on health care reform. The Galen Institute featured much of his remarks in its latest newsletter, including Crowley’s warning to the U.S. – be careful what you wish for.

“So many lessons, so little time.” That was how Brian Lee Crowley of Canada led off his remarks at our major conference, “Lessons from abroad for health reform in the U.S.” on Monday, co-sponsored by the Galen Institute and the International Policy Network in London. (To read Crowley’s remarks Canadian Care: Coming soon to a republic near you, click here)

The presentations by noted experts from Canada, the U.K., and Europe were splendid and offered a sober warning to U.S. policymakers about embarking on a path toward giving government more power and control over health care and health coverage.

The full package of conference materials is available on our website at www.galen.org/content/LessonsFromAbroad. You can view the webcast, read summaries of our speakers’ remarks, and see their PowerPoint presentations. Here is a quick overview:

Noted health policy expert Dr. Ken Thorpe of Emory University led the conference with a keynote speech highlighting the challenges and policy proposals under serious consideration in Washington.

He said it is essential that we refocus our health care delivery and financing on primary care and prevention and modernize our delivery infrastructure to address the chronic illnesses that are consuming an ever greater share of health care resources, especially obesity-related illnesses such as diabetes and hypertension. The third crucial challenge is to cover the uninsured, and he explored options to pay the added costs above the $634 billion set aside in the president’s budget.

The first panel offered an overview of government involvement in the health sectors of their four countries:

Speaker after speaker said, in different ways, that when government controls health care, medical decisions inevitably are made based upon costs, because politicians over-promise on benefits and are unwilling to raise taxes to the levels necessary to finance their commitments.

Practicing physician Dr. Alphonse Crespo said that Switzerland’s imposition of an individual mandate for insurance in 1994 has caused a domino effect toward centralized power over the health sector. “First in the line of fire were public hospitals, which reduced bed numbers by 6% between 1998 and 2000 via forced mergers, closure of acute care units, centralization of more complex technology and rationing of nursing care.

“This downgrading of local hospitals inadvertently created inequities in access to specialized units and sophisticated technology.” More complex surgeries are harder to get, and medical errors, hospital infections, and other complications have soared. The government also has put a lid on new private medical offices, even while there are physician shortages in some areas “because they figured out that if you have fewer physicians, you have fewer billings.”

Dr. Brian Crowley of the Atlantic Institute for Market Studies, and a Galen Institute senior fellow, warned Americans against believing that all of their problems could be solved by emulating the Canadian system. “The administrators of the Canadian health care system enjoy monopolist immunity from dissatisfied customers. The only options for unhappy patients are individual complaints to politicians, letters to the editor, and calls to open-line shows. The old public-sector monopoly model also confers huge power on ever-bigger hospitals and trade unions who, together, exercise a stranglehold on the production of medical services.” He said that the level of political involvement in the Canadian health care system appears to know no bounds, with even the quality of the toast served in Manitoba hospitals becoming a hot political issue.

Dr. Valentin Petkantchin, of the Institut économique Molinari in France, said that France tops many world health care rankings but misplaced efforts at cost containment are leading to an erosion of quality, choice, and access. The French have had access to a pluralistic system of public or private clinics, hospitals, and physicians, but “the government is undermining these pillars of choice and competition. In doing so, France risks making the same mistakes as other countries that are now saddled with waiting lists and other forms of rationing.”

Prof. Wim Groot of Maastricht University in The Netherlands, offered an overview of his country’s major reforms “in order to better use the principle of competition.” The Netherlands replaced its system in which “all residents below a certain income had to enroll in one of the government’s 30 ‘sickness funds’,” because he said it became highly costly and inefficient. The government now defines a benefits package offered by competing plans with a “risk equalization fund” for the insurers; plans compete on quality and price, with efforts to increase transparency of both.

The second panel focused on comparative effectiveness programs:

Dr. John Bridges of Johns Hopkins Bloomberg School of Public Health: “My biggest problem with comparative effectiveness and other health technology assessment systems is that they delay access to life-saving drugs and radically distort the innovation pathways by de facto shortening the lives of patents.”

Prof. Michael Schlander of the University of Applied Economic Sciences and Institute for Innovation & Valuation in Health Care in Germany offered a critique of the British system of comparative effectiveness reviews, NICE. He said that health spending may actually increase when these systems are put in place, that the formulaic approaches to decision making often violate social value judgments about the relative value of human life, and that important clinical evidence is often neglected in government decisions. “Comparative effectiveness reviews will be about cost containment,” he warned.

Dr. Karol Sikora, a noted oncologist with the Imperial College School of Medicine in London who also is director of CancerPartnersUK, said that “good cancer care should be the same in Washington as in Wimbledon,” but that does not happen because British politicians ration access to the best cancer medicines. “The bottom line in government systems is their bottom line,” i.e., costs. The only solution, he said, is “to give patients financial control over their destiny.” But he said that in the U.K., patients aren’t even allowed to know about new drugs. “Having seen firsthand over many years just how inhumane this system can be, it is remarkable that other countries would even consider emulating it.”

Brett Skinner of the Fraser Institute in Canada: “Canada’s federal government certifies both the safety and effectiveness of all new drugs before they can be legally sold. As a result of the various government approval regimes through which all new drugs must pass, Canadians have very low rates of access to innovative medicines via the public health system, with wide variations amongst different provinces. Canadians spend a higher proportion of their post-tax incomes on prescription drugs than Americans, and the Canadian government spends more on health care as a result of increased but avoidable hospitalizations.”

Luncheon Keynotes:

Two physician members of Congress delivered our luncheon keynote addresses. Dr. Tom Price of Georgia, chairman of the Republican Study Committee focused on his five pillars of reform: access, affordability, quality, responsiveness, and innovation. He said he sees the threat of growing bureaucratization and politicization of our health system in the U.S. as compromising all five principles.

Dr. Michael Burgess, Republican of Texas, had the final word saying that “we must move toward a patient-centered system” and the only way to do that is to give patients control over resources so they can make their own decisions about their health care and coverage. That means making insurance financially feasible with tax equity through deductions and/or credits, pooling mechanisms and safety nets for coverage, and basing other reforms on “trusting people, rather than remote bureaucracies, to make the best decisions for themselves and their families.”

(We invited a number of Democratic legislators to speak, but none was able to join us.)

Our international guests also participated in a number of other meetings with Hill staffers, policy experts, and patient group advocates to share their views. My take away from all of the sessions was how quickly control over life-and-death health care decisions can devolve toward political control when a few strategic policies are put in place and how extraordinarily difficult it is to recapture the diversity of choice, innovation, and quality that are sacrificed in the process.